Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure

Nikhil Narang, Ben Chung, Ann Nguyen, Rohan J. Kalathiya, Luke J. Laffin, Luise Holzhauser, Imo A. Ebong, Stephanie A. Besser, Teruhiko Imamura, Bryan A. Smith, Sara Kalantari, Jayant Raikhelkar, Nitasha Sarswat, Gene H. Kim, Valluvan Jeevanandam, Daniel Burkhoff, Gabriel Sayer, Nir Uriel

Research output: Contribution to journalArticle

Abstract

Background: Historically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF. Methods and Results: We conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m2; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001). Conclusions: Clinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.

Original languageEnglish (US)
JournalJournal of Cardiac Failure
DOIs
StateAccepted/In press - Jan 1 2019
Externally publishedYes

Fingerprint

Heart Failure
Hemodynamics
Cardiac Catheterization
Pulmonary Wedge Pressure
Atrial Pressure
Pulmonary Edema
Cardiology
Physical Examination
Cohort Studies
Prospective Studies
Physicians

Keywords

  • Heart failure
  • hemodynamics
  • physical examination

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Narang, N., Chung, B., Nguyen, A., Kalathiya, R. J., Laffin, L. J., Holzhauser, L., ... Uriel, N. (Accepted/In press). Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure. Journal of Cardiac Failure. https://doi.org/10.1016/j.cardfail.2019.08.004

Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure. / Narang, Nikhil; Chung, Ben; Nguyen, Ann; Kalathiya, Rohan J.; Laffin, Luke J.; Holzhauser, Luise; Ebong, Imo A.; Besser, Stephanie A.; Imamura, Teruhiko; Smith, Bryan A.; Kalantari, Sara; Raikhelkar, Jayant; Sarswat, Nitasha; Kim, Gene H.; Jeevanandam, Valluvan; Burkhoff, Daniel; Sayer, Gabriel; Uriel, Nir.

In: Journal of Cardiac Failure, 01.01.2019.

Research output: Contribution to journalArticle

Narang, N, Chung, B, Nguyen, A, Kalathiya, RJ, Laffin, LJ, Holzhauser, L, Ebong, IA, Besser, SA, Imamura, T, Smith, BA, Kalantari, S, Raikhelkar, J, Sarswat, N, Kim, GH, Jeevanandam, V, Burkhoff, D, Sayer, G & Uriel, N 2019, 'Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure', Journal of Cardiac Failure. https://doi.org/10.1016/j.cardfail.2019.08.004
Narang, Nikhil ; Chung, Ben ; Nguyen, Ann ; Kalathiya, Rohan J. ; Laffin, Luke J. ; Holzhauser, Luise ; Ebong, Imo A. ; Besser, Stephanie A. ; Imamura, Teruhiko ; Smith, Bryan A. ; Kalantari, Sara ; Raikhelkar, Jayant ; Sarswat, Nitasha ; Kim, Gene H. ; Jeevanandam, Valluvan ; Burkhoff, Daniel ; Sayer, Gabriel ; Uriel, Nir. / Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure. In: Journal of Cardiac Failure. 2019.
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AU - Chung, Ben

AU - Nguyen, Ann

AU - Kalathiya, Rohan J.

AU - Laffin, Luke J.

AU - Holzhauser, Luise

AU - Ebong, Imo A.

AU - Besser, Stephanie A.

AU - Imamura, Teruhiko

AU - Smith, Bryan A.

AU - Kalantari, Sara

AU - Raikhelkar, Jayant

AU - Sarswat, Nitasha

AU - Kim, Gene H.

AU - Jeevanandam, Valluvan

AU - Burkhoff, Daniel

AU - Sayer, Gabriel

AU - Uriel, Nir

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N2 - Background: Historically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF. Methods and Results: We conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m2; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001). Conclusions: Clinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.

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